Wiki Size of tumor

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rbeaver

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A back tumor was excised. No mention of size of tumor in operative report. Do we use path report to code the size? I thought that size change. Could someone direct me where to go to get information to back my findings.

Thanks
 
All you have to do is query the doctor about what size excision was required to completely remove the mass. You should also query him about how deep he had to excise (ie, dermis, subq, facia, or bone)

your cpt book for 2010 outlines this specifically in the beginning of the musculoskeletal section. If you are using an older book, it wont be there because these are new rules that went into effect in 2010.

Caprice -- cpc
 
When you query the doctor you should also have him amend his note to include the lesion size and depth.
 
Size of lesion vs Size of Incision

The size of the lesion is NOT the same as the size of the incision. In most cases the incision is quite a bit longer than the lesion itself.

The physician MUST dictate the size of the lesion itself, as well as the depth.

If the lesion was limited to the epidermis, use codes from the Integumentary section (depends on whether benign or malignant).
If it is a soft tumor of the back or flank look at CPT code range 21930-21936.

If you are coding from the integumentary system, and the resultant operative wound required layered or complex closure you can code the closure separately (here is where the size of the incision comes in).

If you are coding from the musculoskeletal section, closure is included in the procedure.

In general, for an accurate response to your surgical coding questions, please post the scrubbed operative/procedure note.
Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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